<p>Please provide your credit card information.</p>

<?= open_form() ?>
	<?= flash_message() ?>
	<ul class="form">
		<li class="field text left">
			<label for="FIRSTNAME">Cardholder First Name</label>
			<div><input autocomplete="off" name="FIRSTNAME" value="" id="FIRSTNAME" type="text" class="text"/></div>
		</li>		
		
		<li class="field text right">
			<label for="LASTNAME">Cardholder Last Name</label>
			<div><input autocomplete="off" name="LASTNAME" value="" id="LASTNAME" type="text" class="text"/></div>
		</li>
		
		<li class="field select left">
			<label for="CARD_TYPE">Card Type</label>
			
			<select autocomplete="off" name="CARD_TYPE" id="CARD_TYPE">
				<option value="">&lt;please select&gt;</option>
				<option value="VISA">VISA Credit</option>
				<option value="DELTA">VISA Debit</option>
				<option value="UKE">VISA Electron</option>
				<option value="MC">MasterCard</option>
				<option value="MAESTRO">Maestro</option>
				<option value="AMEX">American Express</option>
				<option value="DC">Diner's Club</option>
				<option value="JCB">JCB Card</option>
				<option value="LASER">Laser</option>
				<option value="SOLO">Solo</option>
			</select>
		</li>

		<li class="field text right">
			<label for="ACCT">Credit Card Number</label>
			<div><input autocomplete="off" name="ACCT" value="" id="ACCT" type="text" class="text"/></div>
		</li>

		<li class="field select left">
			<label for="START_MONTH">Start Date - Month
				<span class="comment">Please specify the card start month if available.</span>
			</label>
			<select autocomplete="off" name="START_MONTH" id="START_MONTH">
				<option value="">&lt;not applicable&gt;</option>
				<? for ($month=1; $month <= 12; $month++): ?>
					<option value="<?= $month ?>"><?= $month ?></option>
				<? endfor ?> 
			</select>
		</li>

		<li class="field text right">
			<label for="START_YEAR">
				Start Date - Year
				<span class="comment">Please specify the card start year if available.</span>
			</label>

			<select autocomplete="off" name="START_YEAR" id="START_YEAR">
				<option value="">&lt;not applicable&gt;</option>
				<?
				  $startYear = Phpr_DateTime::now()->getYear();
				  for ($year=$startYear-10; $year <= $startYear; $year++): ?>
					<option value="<?= $year ?>"><?= $year ?></option>
				<? endfor ?> 
			</select>
		</li>

		<li class="field select left">
			<label for="EXPDATE_MONTH">Expiration Date - Month</label>
			<select autocomplete="off" name="EXPDATE_MONTH" id="EXPDATE_MONTH">
				<? for ($month=1; $month <= 12; $month++): ?>
					<option value="<?= $month ?>"><?= $month ?></option>
				<? endfor ?> 
			</select>
		</li>

		<li class="field text right">
			<label for="EXPDATE_YEAR">Expiration Date - Year</label>

			<select autocomplete="off" name="EXPDATE_YEAR" id="EXPDATE_YEAR">
				<?
				  $startYear = Phpr_DateTime::now()->getYear();
				  for ($year=$startYear; $year <= $startYear + 10; $year++): ?>
					<option value="<?= $year ?>"><?= $year ?></option>
				<? endfor ?> 
			</select>
		</li>

		<li class="field text left">
			<label for="CVV2">
				CVV2
				<span class="comment">For MasterCard, Visa, and Discover - the last three digits in the signature area on the back of the card. For American Express - four digits on the front of the card.</span>
			</label>
			
			<div><input autocomplete="off" name="CVV2" value="" id="CVV2" type="text" class="text"/></div>
		</li>		
		
		<li class="field text right">
			<label for="ISSUENUMBER">
				Issue Number
				<span class="comment">Older Switch cards only. 1 or 2 digits as printed on the card.</span>
			</label>
			
			<div><input autocomplete="off" name="ISSUENUMBER" value="" id="ISSUENUMBER" type="text" class="text"/></div>
		</li>
	</ul>
	<div class="clear"></div>
	<input type="button" onclick="return $(this).getForm().sendRequest('shop:on_pay')" value="Submit"/>
</form>